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Patient Registration Form-Child

Eau Claire Family Dental

1018 Regis Court,Eau Claire, WI, 54701(715) 832-8063

Patient Information( * mandatory to fill )

First Name*

Last Name*

Middle Name

Date Of Birth*

Age

Gender*

Social Security Number

Address*

City*

State*

Zip*

Home Phone Number

Cell Phone Number

Work Phone Number

Email

Preferred Method of Contact*

Text Message

Email

Cell Phone

Home Phone

PATIENT INFORMATION( * mandatory to fill )

Patient or Parent's Employer

Spouse or Parent's Name

Employer

Whom can we think for referring you ?

Responsible Party's Information( * mandatory to fill )

Name of Person Responsible for this Account

Relationship To Patient

Cell Phone Number

Home Phone Number

Work Phone Number

Address*

City*

State*

Zip*

Social Security Number

Date of Birth*

Employer

Insurance Information( * mandatory to fill )

Name of Insured

Relationship to Patient

DOB of Insured

SSN#

Employer Name

Insurance Name

Insurance Phone

Ext

Claim's Address

City

State

Zipcode

Policy Number

Group Number

Do you have any Additional Insurance ?

Yes

No

ADDITIONAL INSURANCE( * mandatory to fill )

Name of Insured

Relationship To Patient

DOB

Social Security Number

Employer Name

Insurance Name

Insurance Phone

Ext

Claim's Address

City

State

Zipcode

Policy Number

Group Number

AUTHORIZATION( * mandatory to fill )

I certify that I, and/or dependent(s) have insurance coverage and assign directly to this dental office all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.